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Seldinger technique for in-office tracheoesophageal puncture.

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Tracheoesophageal puncture (TEP) with speaking-valve placement is the preferred method of voice rehabilitation in patients postlaryngectomy. (1-4) Puncture may be performed (1) primarily at the time of extirpative surgery or (2) secondarily after wounds have healed). (1,4,5)

The advantages of in-office TEP include safety, cost savings, and better visualization. (6-8)

Our previously described technique was successful in 91% of attempts, (9) but we continued to seek improvements. To that end, we have simplified the procedure by performing the catheter placement over a guidewire. In this article, we describe our modified Seldinger technique for in-office, unsedated TEP.

The patient is assessed by the multidisciplinary Head and Neck team. This evaluation includes an assessment of the stoma, patient characteristics likely to affect prosthesis management (e.g., motivation and dexterity), and a fluoroscopic swallowing study with an insufflation test to look for a mobile neopharyngoesophageal segment that will provide a suitable vibratory segment.

The appropriate consents are obtained. Two clinicians are required--one to perform the esophagoscopy and one to perform the puncture. The patient is seated in an examination chair in the upright position, and the stoma is assessed to identify the appropriate site for puncture. The preferred site is at the midline and at least 6 mm inferior (caudal) to the 12 o'clock position at the epithelial-mucosal interface of the stoma. This is to enable easy occlusion of the stoma lumen for redirection of airflow into the valve without obstruction of the valve lumen by the patient's digital pressure. The nares are sprayed with topical 1% lidocaine mixed with phenylephrine. A transnasal esophagoscope is passed through the most patent naris into the hypopharynx and pharyngoesophageal segment. Air is insufflated to distend the lumen. The light at the tip of the esophagoscope is easily seen through the anterior esophageal wall in the stoma. A Q-tip cotton swab is used to palpate the common esophageal wall within the stoma, and its position is observed directly through the endoscope. The site is then infiltrated with 1 to 2 ml of 1% lidocaine with epinephrine. A small volume is used so that the common wall at the puncture site will not become distorted.

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The equipment necessary to perform the procedure is shown in figure 1. While air is insufflated within the esophageal lumen, an 18-gauge hypodermic needle is passed through the common wall under direct vision (figure 2, A). Insufflation protects the posterior esophageal wall from inadvertent injury and allows for a direct view of the needle tip as it enters the esophageal lumen. A guidewire (Jagwire; Boston Scientific; Natick, Mass.) is then passed through the needle into the esophagus, again under direct vision (figure 2, B). The needle is removed to the common wall surface; during extraction, a small amount of dilation is accomplished with the needle tip by moving the needle in and out of the puncture site. A small pipette with a graduated diameter (Samco Scientific; San Fernando, Calif.) is then lubricated and threaded over the guidewire and passed into the puncture, dilating the site up to 14F. The bulb end of the pipette is removed with a scissors to allow for passage over the guidewire. The pipette is left in situ for 2 minutes. Then the 18-gauge needle is used to place a small hole in the tip of a 14F catheter (Bard Clean Cath; C.R. Bard; Covington, Ga.). The pipette is then removed, and the catheter is placed over the guidewire into the esophagus. The guidewire is then removed, a knot is tied in the catheter to prevent reflux of gastric contents, and the catheter is sutured to the cervical skin with 0 nylon ligature The entire procedure is performed under guidance of the esophagoscope.

For follow-up, the patient is seen 1 week postoperatively by the speech-language pathologist. At that time, the patient undergoes either placement of a larger catheter if further dilation is needed or placement of the voicing valve.

References

(1.) Bozec A, Poissonnet G, Chamorey E, et al. Results of vocal rehabilitation using tracheoesophageal voice prosthesis after total laryngectomy and their predictive factors. Eur Arch Otorhinolaryngol 2010;267(5):751-8.

(2.) Attieh AY, Searl J, Shahaltough NH, et al. Voice restoration following total laryngectomy by tracheoesophageal prosthesis: Effect on patients' quality of life and voice handicap in Jordan. Health Qual Life Outcomes 2008;6:26.

(3.) Stewart MG, Chen AY, Stach CB. Outcomes analysis of voice and quality of life in patients with laryngeal cancer. Arch Otolaryngol Head Neck Surg 1998;124(2):143-8.

(4.) Malik T, Bruce I, Cherry J. Surgical complications of tracheooesophageal puncture and speech valves. Curr Opin Otolaryngol Head Neck Surg 2007;15(2):117-22.

(5.) Emerick KS, Tomycz L, Bradford CR, et al. Primary versus secondary tracheoesophageal puncture in salvage total laryngectomy following chemoradiation. Otolaryngol Head Neck Surg 2009;140(3):386-90.

(6.) Bach KK, Postma GN, Koufman JA. In-office tracheoesophageal puncture using transnasal esophagoscopy. Laryngoscope 2003; 113 (1):173-6.

(7.) Desyatnikova S, Caro JJ, Andersen PE, et al. Tracheoesophageal puncture in the office setting with local anesthesia. Ann Otol Rhinol Laryngo1 2001;110(7 Pt 1):613-16.

(8.) Eerenstein SE, Schouwenberg PE Secondary tracheoesophageal puncture with local anesthesia. Laryngoscope 2002; 112(4):634-7.

(9.) Doctor VS, Enepekides DJ, Farwell DG, Belafsky PC. Transnasal oesophagoscopy-guided in-office secondary tracheoesophageal puncture. J Laryngol Otol 2008;122(3):303-6.

Jacqui Allen, MBChB, FRACS; Peter C. Belafsky, MD, PhD

From the Center for Voice and Swallowing, Department of Otolaryngology, University of California Davis Medical Center, Sacramento.
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Title Annotation:DYSPHAGIA CLINIC
Author:Allen, Jacqui; Belafsky, Peter C.
Publication:Ear, Nose and Throat Journal
Article Type:Report
Geographic Code:1USA
Date:Aug 1, 2010
Words:918
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